Provider Demographics
NPI:1811628324
Name:COSTELLO, MEGAN G
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:G
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 BUSH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-5297
Mailing Address - Country:US
Mailing Address - Phone:415-308-6406
Mailing Address - Fax:
Practice Address - Street 1:1801 BUSH ST STE 210
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5297
Practice Address - Country:US
Practice Address - Phone:415-308-6406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51645106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist